Adult Volunteer Applications

 
 

Home Address:

 
 
 
 
 
 
 
 
Skills and Interests

Special Skills (Ex: Photography):

Please list any previous volunteer experience:

Have you volunteered at a MSHA facility?


 
Preferences in Volunteering

Is there a group with whom you are particularly interested in working? (Check all that apply)





Briefly explain why you are interested in volunteering:

 

Are you required to volunteer?


 

How did you hear about our Volunteer Program?

What type of recognition do you prefer? (check all that apply)





Availability

At what times are you interested in volunteering? Many of our areas work in four hour shifts, but some areas require less time. (check all that apply)




What days are you interested in volunteering? (Check all that apply)







Background Verification

Do you have any physical limitations which might limit your ability to perform certain types of work?


 
 
 

Have you ever been convicted of a criminal offense?


 

If you are considering volunteering as a Courtesy Cart driver, you must be a minimum of 18 years of age, have a current valid driver’s license, and have had no driving violations within the past 1 year.

Agreement

I understand and agree that at no time will any information regarding patients of Mountain  States Health Alliance be revealed to anyone other than those authorized to receive it.  I understand that the giving of the information concerning a patient to those not authorized to receive such information is unlawful and shall be sufficient cause for my immediate dismissal.
 

I agree to any necessary health screening required by the hospital and understand my volunteer assignment is contingent upon successful completion of this screening.  I UNDERSTAND I MUST HAVE A TB SKIN TEST AND FLU VACCINATION BEFORE I CAN BEGIN VOLUNTEERING.  The hospital will perform these at no charge to the volunteer. 

I understand that false statements made as a part of this enrollment may be considered sufficient cause for dismissal.

I authorize and consent for all named references and educational institutions or previous places of employment to release any personal and/or professional information about me to the MSHA Volunteer Office.  I also consent to a law enforcement record search and/or any other background investigation of me if chosen by the Volunteer Office.  I understand I have consented to these things as described herein, and in doing so, I further release, hold harmless, and indemnify Mountain States Health Alliance, the Volunteer Office, and any and all MSHA employees, officers, directors, and/or authorized agents, as well as those individuals or entities supplying such information about me, and/or conducting such search and/or investigation, from any liability, claims and/or causes of action as a result of any such inquiry, search and/or investigation.

I UNDERSTAND THAT IF I AM ACCEPTED AS A VOLUNTEER: 

v  I will abide by Mountain States Health Alliance’s general policy concerning patient confidentiality.

v  My assignment is on a probationary basis for a period of 60 days.

v  I voluntarily offer my services with a clear understanding that there is no monetary compensation due to me as a result of my services, and MSHA is not legally liable for any worker’s compensation coverage or other similar benefits as a result of my services hereunder.

v  Photos taken while participating as a MSHA volunteer or at special functions may be used for promotional reasons.

v  I will observe all hospital regulations.

 

 

Submitting this form is your electronic signature and your acceptance of the Agreement above.

Do you agree to the statement above?